Missed Opportunities for Hepatitis C Testing in Opioid Treatment Programs

HCV has surpassed HIV as a cause of death in the United States and is particularly prevalent among injection drug users. I examined the availability of on-site HCV testing in a nationally representative sample of opioid treatment programs. Nearly 68% of these programs had the staff required for HCV testing, but only 34% offered on-site testing. Availability of on-site testing increased only slightly with the proportion of injection drug users among clients. The limited HCV testing services in opioid treatment programs is a key challenge to reducing HCV in the US population.HCV recently surpassed HIV as a cause of death in the United States.1,2 Approximately 3.2 million people nationwide are living with chronic hepatitis, but most are unaware of their status because of limited opportunities for testing.3–6 Persons who inject drugs are particularly at risk for HCV infection as a result of sharing and reusing of needles.4,7 The estimated prevalence of antibodies to HCV (anti-HCV) among injection drug users ranges from 35% to 65%.8 The Centers for Disease Control and Prevention (CDC) thus recommends routine HCV testing for all current or former injection drug users.1,9 Offering HCV testing services in drug abuse treatment programs could help increase HCV case finding and reduce transmission.10,11 It could also help foster the adoption of preventive behaviors: knowledge of one’s anti-HCV status may indeed lead to safer injection practices (or other protective behaviors).12,13I examined the availability of on-site HCV testing services in opioid treatment programs (i.e., physical facilities with resources dedicated specifically to treating opiate dependence with methadone, buprenorphine, or both).14,15 Opioid treatment programs treat both persons who inject drugs and people who have opiate addiction but do not inject drugs. The current recommended HCV testing protocol requires the collection of venous blood, performed by qualified staff (i.e., phlebotomists).16 However, the availability of (1) human resources required to offer HCV testing services and (2) on-site HCV testing services at opioid treatment programs nationwide is not known. I examined relations among the availability of on-site HCV testing services, human resources for HCV testing, and the proportion of injection drug users among opioid treatment program clients.     

Survey of US Correctional Institutions for Routine HCV Testing

To ascertain HCV testing practices among US prisons and jails, we conducted a survey study in 2012, consisting of medical directors of all US state prisons and 40 of the largest US jails, that demonstrated a minority of US prisons and jails conduct routine HCV testing. Routine voluntary HCV testing in correctional facilities is urgently needed to increase diagnosis, enable risk-reduction counseling and preventive health care, and facilitate evaluation for antiviral treatment.There are an estimated 4 to 7 million persons in the United States infected with HCV.1,2 Morbidity and mortality from HCV are increasing and in 2007, death from HCV exceeded that from HIV infection for the first time.3,4 Persons who inject drugs are at increased risk for HCV infection and for being incarcerated. Multiple studies have demonstrated high HCV prevalence rates among persons behind bars.5–7 In 2010, the Institute of Medicine (IOM) called for the development of comprehensive viral hepatitis services for incarcerated populations including offering testing, hepatitis B virus vaccination, education, and medical management in partnership with community providers.8Despite the Centers for Disease Control and Prevention (CDC) releasing HCV testing recommendations in 1998 and subsequent recommendations for prevention and control of viral hepatitis within correctional facilities in 2003,9-10 recent studies estimate that 50% of persons infected with HCV are unaware of their infection,11–14 thus reducing opportunities for risk-reduction counseling and treatment. In response to this, the CDC updated HCV testing recommendations for the US general population in 2012, which added at least 1-time testing among persons born between 1945 and 1965, now commonly referred to as the “birth cohort” screening recommendations.15 However, the 2012 recommendations did not provide a specific testing recommendation for incarcerated individuals. Given the increased prevalence of HCV among criminal justice populations, we conducted a survey among US prisons and jails to gain a better understanding of current HCV testing practices within correctional facilities.     

Hepatitis C Screening Rate Among Underserved Adults With Serious Mental Illness Receiving Care in California Community Mental Health Centers

Although HCV is more prevalent among people with severe mental illness (SMI; e.g., schizophrenia, bipolar disorder) than in the general population (17% vs 1%), no large previous studies have examined HCV screening in this population. In this cross-sectional study, we examined administrative data for 57 170 California Medicaid enrollees with SMI to identify prevalence and predictors of HCV screening from October 2010 through September 2011. Only 4.7% (2674 of 57 170) received HCV screening, with strongest predictors being nonpsychiatric health care utilization and comorbid substance abuse.People with severe mental illness (SMI; e.g., schizophrenia, bipolar disorder) die 25 years earlier than the general population.1 Although cardiovascular disease represents the primary cause of mortality,1 blood-borne infectious diseases are another contributor.2 HCV is the most prevalent blood-borne infection in the United States; by the best available estimates, more than 17% of people with SMI have HCV, compared with only 1% of the general US population.2 Although prevention, early detection, and treatment are crucial interventions for high-risk populations, most people with SMI do not receive these services.3 To our knowledge, no previous large studies have examined HCV testing among this high-risk population served in the public mental health system.4     

Prevalence of HCV Infection Among Clients in Community-Based Health Settings in Hawaii, 2002–2010: Assessing Risk Factors

Objectives. We sought to determine the prevalence of HCV infection and identify risk factors associated with HCV infection among at-risk clients presenting to community-based health settings in Hawaii.Methods. Clients from 23 community-based sites were administered risk factor questionnaires and screened for HCV antibodies from December 2002 through May 2010. We performed univariate and multivariate logistic regression analyses.Results. Of 3306 participants included in the analysis, 390 (11.8%) tested antibody positive for HCV. Highest HCV antibody prevalence (17.0%) was in persons 45 to 64 years old compared with all other age groups. Significant independent risk factors were current or prior injection drug use (P < .001), blood transfusion prior to July 1992 (P = .002), and having an HCV-infected sex partner (P = .03). Stratification by gender revealed sexual exposure to be significant for males (P = .001).Conclusions. Despite Hawaii’s ethnic diversity, high hepatocellular carcinoma incidence, and a statewide syringe exchange program in place since the early 1990s, our HCV prevalence and risk factor findings are remarkably consistent with those reported from the mainland United States. Hence, effective interventions identified from US mainland population studies should be generalizable to Hawaii.Hepatitis C is the most prevalent chronic blood-borne viral infection in the United States, with an estimated 1.3% of the population chronically infected.1 Chronic HCV infection is often asymptomatic; approximately 75% of infected persons may be unaware that they are infected.2 Transmission is mainly through direct blood-to-blood contact, and the most common risk factor in the United States is the sharing of injection drug use equipment.1,2 Complications from HCV infection include cirrhosis, hepatocellular carcinoma (HCC), and end-stage liver disease; more than one third of liver transplants in the United States can be attributed to HCV.3 There is currently no vaccine,4 and until recently, standard therapy with pegylated interferon and ribavirin achieved a sustained virologic response in only 40% to 50% of patients.5,6In May 2011, the US Food and Drug Administration approved 2 new HCV-specific protease inhibitors for the treatment of chronic genotype 1 HCV infections: boceprevir7,8 and telaprevir.9,10 In combination with standard therapy, these drugs have achieved significantly higher rates of sustained virologic response: up to 67% to 75%.7,10 Achieving sustained virologic response is key to reducing mortality, HCC, and other comorbidities.11,12 With such a large percentage of HCV-infected individuals unaware of their status and new successful treatments available, there is now increased rationale for health providers to screen their clients for chronic HCV infection.The population of Hawaii differs from that of the mainland United States on a number of key factors related to HCV and HCC. Hawaii has the highest incidence of HCC nationally.13 Asian/Pacific Islanders have the highest incidence of HCC in the United States,13 and 57% of the Hawaii’s population is Asian, either alone or in combination with other ethnic groups.14 The high HCC incidence among Asian/Pacific Islanders is attributed in large part to chronic hepatitis B virus (HBV) infection,13,15 and the identification and treatment of persons with chronic HBV or HCV infection is an important public health priority in Hawaii. In addition, Hawaii implemented a statewide syringe exchange program in the early 1990s, the first state to do so.16 The risk factor demonstrating the strongest association with HCV infection in the United States is injection drug use,1,17 and syringe exchange programs have demonstrated efficacy in reducing HCV infection among injection drug users.18,19To our knowledge, only 3 HCV prevalence studies have been conducted in Hawaii; however, each focused on a specific well-defined subgroup population: patients with HCC,20 HIV-infected persons enrolled in a state drug assistance plan,21 and adults from a homeless shelter.22The Adult Viral Hepatitis Prevention Program of the Hawaii State Department of Health, which offers risk-based HCV antibody testing based on reported national risk factors,1,23 has been collecting data on persons undergoing screening since 2002. We investigated the prevalence of HCV antibody positivity among at-risk clients of community-based health programs in Hawaii and identified demographic characteristics and independent risk factors associated with HCV infection.     

Epidemiology of Hepatitis C Virus in Pennsylvania State Prisons, 2004–2012: Limitations of 1945–1965 Birth Cohort Screening in Correctional Settings

Objectives. We described hepatitis C virus antibody (anti-HCV) prevalence in a state prison system and retrospectively evaluated the case-finding performance of targeted testing of the 1945 to 1965 birth cohort in this population.Methods. We used observational data from universal testing of Pennsylvania state prison entrants (June 2004–December 2012) to determine anti-HCV prevalence by birth cohort. We compared anti-HCV prevalence and the burden of anti-HCV in the 1945 to 1965 birth cohort with that in all other birth years.Results. Anti-HCV prevalence among 101 727 adults entering prison was 18.1%. Prevalence was highest among those born from 1945 to 1965, but most anti-HCV cases were in people born after 1965. Targeted testing of the 1945 to 1965 birth cohort would have identified a decreasing proportion of cases with time.Conclusions. HCV is endemic in correctional populations. Targeted testing of the 1945 to 1965 birth cohort would produce a high yield of positive test results but would identify only a minority of cases. We recommend universal anti-HCV screening in correctional settings to allow for maximum case identification, secondary prevention, and treatment of affected prisoners.HCV is the most common blood-borne viral infection in the United States, with an estimated 4.1 million persons having been exposed to the virus, and 3.2 million people, or about 1.3% of the population, having chronic HCV infection.1 Although overall HCV prevalence in the United States is declining,2 recently there have been multiple reports of outbreaks among young people, predominantly in suburban and rural areas.3–5 The primary mode of HCV transmission is injection drug use,6 and as a result, HCV disproportionately affects people in contact with the criminal justice system.7 An estimated 17.4% of US state prisoners were HCV antibody positive (anti-HCV positive) in 2006, and perhaps 28.5% to 32.8% of the US case burden was in contact with the criminal justice system in that year.8People may be infected with HCV for several decades without symptoms. At least half of the affected individuals in the United States are unaware of their infection9 and thus are unable to receive treatment. Without treatment, HCV infection can lead to cirrhosis, chronic liver disease, and hepatocellular carcinoma.10–12 At current treatment rates, HCV will kill nearly 380 000 people in the United States by 2030 and more than 1 million by 2060.13Until recently, the Centers for Disease Control and Prevention (CDC) recommended HCV testing only for people with known or at high risk for past or current HCV exposure, including people who had ever injected drugs, who had certain medical conditions, or who had received blood transfusions or blood products before HCV screening of such products became routine.14 In recognition of the urgent need to diagnose and treat extant infections and reduce HCV-related mortality, in 2012 the CDC also recommended 1-time HCV testing of all people born between 1945 and 1965.14 This birth cohort was selected on the basis of findings from the National Health and Nutrition Examination Survey (NHANES). NHANES is an ongoing nationally representative survey of the civilian, noninstitutionalized population. NHANES data from 1999 to 2008 indicated that 81.6% of anti-HCV–positive people in the United States were born between 1945 and 1965.15 However, an acknowledged limitation of the NHANES data in assessing the epidemiology of HCV is the exclusion of incarcerated people from the sample.1 As such, it is unclear how applicable the 1945 to 1965 birth cohort screening recommendation may be for prisoner populations.The Federal Bureau of Prisons now recommends HCV antibody testing for all inmates who request a test or report risk factors for infection.16 This approach assumes that inmates will reliably report a history of injection drug use, but concerns about self-incrimination and confidentiality may prevent this disclosure. Although 1 study has reported success in using risk-based testing to identify acute HCV in an incarcerated population,17 that study did not assess the proportion of all chronic HCV cases identified by risk-based testing. Analysis of data from a large representative sample of prison entrants found that testing only those inmates who reported injection drug use would have identified 56% of anti-HCV–positive women and just 35% of anti-HCV–positive men.18Given the high anti-HCV prevalence and limited case-finding performance of risk-based HCV screening in correctional settings, universal screening has been suggested as an alternative approach.19 If, however, HCV infection in the correctional population is concentrated in the 1945 to 1965 birth cohort, targeting testing toward this group may be an efficient and cost-effective approach to HCV case finding.20 Limited recent epidemiological data on HCV prevalence in correctional settings hamper evaluation of these different approaches to HCV testing. We present data from universal HCV screening on entry to state prisons in Pennsylvania and consider the case-finding performance of the CDC 1945 to 1965 birth cohort recommendation in this setting.     

Impact of individual-, environmental-, and policy-level factors on health care utilization among US farmworkers

Objectives. We examined individual-, environmental-, and policy-level correlates of US farmworker health care utilization, guided by the behavioral model for vulnerable populations and the ecological model.Methods. The 2006 and 2007 administrations of the National Agricultural Workers Survey (n = 2884) provided the primary data. Geographic information systems, the 2005 Uniform Data System, and rurality and border proximity indices provided environmental variables. To identify factors associated with health care use, we performed logistic regression using weighted hierarchical linear modeling.Results. Approximately half (55.3%) of farmworkers utilized US health care in the previous 2 years. Several factors were independently associated with use at the individual level (gender, immigration and migrant status, English proficiency, transportation access, health status, and non-US health care utilization), the environmental level (proximity to US–Mexico border), and the policy level (insurance status and workplace payment structure). County Federally Qualified Health Center resources were not independently associated.Conclusions. We identified farmworkers at greatest risk for poor access. We made recommendations for change to farmworker health care access at all 3 levels of influence, emphasizing Federally Qualified Health Center service delivery.US farmworkers face significant disease burden¹ and excessive mortality rates for some diseases (e.g., certain cancers and tuberculosis) and injuries.² Disparities in health outcomes likely stem from occupational exposures and socioeconomic and political vulnerabilities. US farmworkers are typically Hispanic with limited education, income, and English proficiency.³ Approximately half are unauthorized to work in the United States.³ Despite marked disease burden, health care utilization appears to be low.^1,4–9 For example, only approximately half of California farmworkers received medical care in the previous year.⁶ This rate parallels that of health care utilization for US Hispanics, of whom approximately half made an ambulatory care visit in the previous year, compared with 75.7% of non-Hispanic Whites.¹⁰ Disparities in dental care have a comparable pattern.^6,8,11,12 However, utilization of preventive health services is lower for farmworkers^5,7,13,14 than it is for both US Hispanics and non-Hispanic Whites.^15,16Farmworkers face numerous barriers to health care^1,4,17: lack of insurance and knowledge of how to use or obtain it,^6,18 cost,^{5,6,12,13,18–20} lack of transportation,^{6,12,13,19–21} not knowing how to access care,^6,18,20,21 few services in the area or limited hours,^12,20,21 difficulty leaving work,¹⁹ lack of time,^5,13,19 language differences,^6,8,18–20 and fear of the medical system,¹³ losing employment,⁶ and immigration officials.²¹ Few studies have examined correlates of health care use among farmworkers. Those that have are outdated or limited in representativeness.^5,7,14,22,23 Thus, we systematically examined correlates of US health care use in a nationally representative sample of farmworkers, using recently collected data. The sampling strategy and application of postsampling weights enhance generalizability. We selected correlates on the basis of previous literature and the behavioral model for vulnerable populations.²⁴ The behavioral model posits that predisposing, enabling, and need characteristics influence health care use.²⁵ The ecological model, which specifies several levels of influence on behavior (e.g., policy, environmental, intrapersonal),²⁶ provided the overall theoretical framework. To our knowledge, we are the first to extensively examine multilevel correlates of farmworker health care use. We sought to identify farmworkers at greatest risk for low health care use and to suggest areas for intervention at all 3 levels of influence so that farmworker service provision can be improved.     

Predictors of Tobacco Use Among New York State Addiction Treatment Patients

Objectives. We used admissions data from the New York State addiction treatment system to assess patient self-reported tobacco use and factors associated with tobacco use.Methods. We compared prevalence of tobacco use in the state addiction treatment system with that of a national sample of people receiving addiction treatment and with that of the New York general population in 2005 to 2008. A random effects logistic model assessed relationships between patient- and program-level variables and tobacco use.Results. Prevalence of tobacco use in the New York treatment system was similar to that in national addiction treatment data and was 3 to 4 times higher than that in the general population. Co-occurring mental illness, opiate use, methadone treatment, and being a child of a substance-abusing parent were associated with higher rates of tobacco use.Conclusions. We call on federal leadership to build capacity to address tobacco use in addiction treatment, and we call on state leadership to implement tobacco-free grounds policies in addiction treatment systems.Since the 1964 Surgeon General’s report,1 public health and policy efforts have decreased smoking prevalence in the United States from 40% to 18%.2,3 The decrease in smoking since 2005 has been slight,4 however, and smoking is now concentrated in subgroups defined by demographics,5 diagnosis,6 or behavior.7–9 Behavioral health populations, especially, have not benefited from the overall population decline in smoking prevalence.10 People with mental health diagnoses are twice as likely to smoke as those without,11 and the highest prevalence rates reported are among people who seek treatment for alcohol or drug addiction. National Survey on Drug Use and Health (NSDUH) data show that, among people who reported past-year addiction treatment, annual smoking prevalence for 2000 to 2009 ranged from 67% to 75%.12Four million people receive addiction treatment annually, and 2.3 million receive services in specialty addiction programs.13 If 70% are smokers,12 then 1.6 million smokers enter such programs annually. Year after year, these settings serve a substantive proportion of the 43.8 million US adult smokers.5 Despite high rates of tobacco use, only 1 in 5 addiction treatment facilities in the United States has the financial resources to provide tobacco cessation services.14 Availability of nicotine replacement therapy in addiction programs decreased over 4 years (from 38% to 34%),15 and 40% of programs providing cessation counseling in 2006 to 2008 later discontinued this service.16 According to the 2011 National Survey of Substance Abuse Treatment Services (N-SSATS), only half of all addiction treatment programs screen clients for tobacco use.17Three fourths of all addiction treatment is provided in the public sector,18,19 and regulation and policy setting for these programs are centralized in Single State Agencies for Substance Abuse Services. Such agencies could disseminate tobacco practice guidelines, mandate counselor education on tobacco dependence,20 or reimburse programs for tobacco-related services.21 Several state addiction treatment systems have initiated or contemplated tobacco control efforts.22–24In July 2008, the New York Office of Alcoholism and Substance Abuse Services (OASAS) mandated smoke-free grounds and treatment of tobacco dependence for patients in addiction treatment.25 The largest such policy in the United States, it affects approximately 1000 programs, 20 000 staff, and 300 000 annual treatment admissions. Interviewing program administrators before and after the regulation, Brown et al.26 found increased tobacco screening and cessation services for patients. Surveying patients before and after the policy, another study found that smoking prevalence decreased from 69% to 63% (P < .05) and that tobacco-related services increased in methadone treatment settings but decreased in residential treatment.27 Studies assessing clinicians’ perspectives on implementation of the OASAS tobacco regulation identified both positive experiences (e.g., increased patient awareness about tobacco abuse) and negative experiences (e.g., enforcement difficulties),28 coupled with perceived increases in program-level commitment of resources and enforcement efforts over time.29,30Before implementing its tobacco control policy, OASAS included tobacco use status in the patient admission record. The resulting data set permits assessment of the relationships between tobacco use and other factors in statewide addiction treatment samples. By comparison, a review of 42 addiction treatment studies reporting smoking prevalence included sample sizes ranging from 29 to 3472.12NSDUH epidemiological data have been used to assess smoking prevalence among people with mental illness,31 people with concurrent alcohol and illicit drug misuse,32 and people receiving addictions treatment in the past year.12 We know of no studies using NSDUH or similar national data sets to explore factors associated with tobacco use in the addiction treatment population. Such data are of interest because tobacco policies in addictions treatment have potential to reduce tobacco use in a population in which use is highest, in which users are concentrated, and in which the burden of tobacco-related mortality is disproportionate.33,34We used admissions data from the New York State addiction treatment system (OASAS) over a 6-year period to estimate prevalence of tobacco use. Comparison with statewide data reflects how much people enrolled in the New York addiction treatment system may smoke in comparison with all New York State residents. Comparison with NSDUH data reflects how much people enrolled in the New York addiction treatment system may smoke in comparison with a national sample of people receiving addiction treatment. We also assessed how program and patient characteristics may be associated with tobacco use in this population.     

Public health implications of rapid hepatitis C screening with an oral swab for community-based organizations serving high-risk populations

Objectives. Between April and September of 2009 we evaluated the accuracy of the OraQuick HCV rapid antibody test and assessed its feasibility for use by community-based organizations (CBOs) serving populations at high risk for HCV in New York City.Methods. We compared the results of screening by OraQuick (oral swab) and enzyme immunoassay (EIA; blood draw). We performed ribonucleic acid polymerase chain reaction testing for discordant results. We also assessed research staff perceptions through a survey and focus group.Results. Overall, 97.5% of OraQuick and EIA results matched. Testing of discordant samples indicated that the rapid test was more likely than the EIA to provide a correct diagnosis. Research staff preferred the rapid test and identified challenges that would be overcome with its use. CBOs could benefit from increased testing capacity, and clients might benefit from more rapid access to education, counseling, and referrals.Conclusions. OraQuick''s accuracy is comparable to the EIA. The oral swab rapid test could help HCV screening programs reach individuals unaware of their status and expand testing into nonclinical settings such as mobile units.The World Health Organization estimates that 170 million people—3% of the global population—are infected with HCV.¹ In the United States the prevalence of anti-HCV positivity is estimated to be 4.1 million, or 1.6% of the population.² The estimated 2.2% prevalence of anti-HCV positivity among New York City residents is higher than that of the US population.³Approximately 75% to 85% of HCV infections become chronic increasing the risk of liver disease and progression to cirrhosis and hepatocellular carcinoma.⁴ HCV is a major contributor to cirrhosis-related death and is the leading indication for liver transplantation in the United States.⁵ Treatment with the current standard-of-care regimens of pegylated interferon and ribavirin can achieve a sustained viral response in 40% to 70% of cases, depending on genotype.^6,7 However, many HCV-infected individuals are unaware of their status because of insufficient availability of HCV screening and education.^8–10The enzyme immunoassay (EIA) that tests for antibodies to HCV infection is the most commonly used HCV screening test. This EIA testing method poses several challenges in high-risk populations such as injection drug users (IDUs), the homeless, currently or formerly incarcerated people, and immigrants. Many in these groups are uninsured or underinsured and face barriers to accessing health care. EIA testing requires phlebotomy and laboratory analysis of specimens, but this limits testing in nonclinical settings and requires patients to return to the testing site to receive results.¹¹ Among current or former IDUs, phlebotomy creates additional challenges, such as finding a usable vein.¹²The adoption of HIV rapid testing has been shown to increase the proportion of people receiving posttest counseling and test results, as well as referral for medical evaluation and treatment, if indicated.^13,14 A rapid test for HCV would allow individuals to be tested and learn the result in a single visit, while still connected to a health care provider, facilitating follow-up polymerase chain reaction (PCR) testing to confirm the presence of HCV ribonucleic acid and entry into medical care and other supportive services.Rapid HCV testing via oral fluid may offer additional benefits for testing programs and their staff. With a reduced need for phlebotomy, risk of exposure to blood-borne pathogens through needlestick injuries is also decreased. Although training is required for test administration, the level of technical skill is less than that required to perform phlebotomy, thereby enabling a broader range of staff to administer tests. We compared the effectiveness of the OraQuick HCV rapid test and the EIA in detecting HCV antibodies and assessed the feasibility of OraQuick''s use in urban outreach testing programs serving populations at high risk for HCV infection. We did not determine the sensitivity of the OraQuick test.     

The association between perceived discrimination and obesity in a population-based multiracial and multiethnic adult sample

Objectives. We examined whether perceived chronic discrimination was related to excess body fat accumulation in a random, multiethnic, population-based sample of US adults.Methods. We used multivariate multinomial logistic regression and logistic regression analyses to examine the relationship between interpersonal experiences of perceived chronic discrimination and body mass index and high-risk waist circumference.Results. Consistent with other studies, our analyses showed that perceived unfair treatment was associated with increased abdominal obesity. Compared with Irish, Jewish, Polish, and Italian Whites who did not experience perceived chronic discrimination, Irish, Jewish, Polish, and Italian Whites who perceived chronic discrimination were 2 to 6 times more likely to have a high-risk waist circumference. No significant relationship between perceived discrimination and the obesity measures was found among the other Whites, Blacks, or Hispanics.Conclusions. These findings are not completely unsupported. White ethnic groups including Polish, Italians, Jews, and Irish have historically been discriminated against in the United States, and other recent research suggests that they experience higher levels of perceived discrimination than do other Whites and that these experiences adversely affect their health.It is estimated that 2 of every 3 adults in the United States are overweight or obese.^1,2 Obesity is a major risk factor for chronic health conditions, such as type 2 diabetes, coronary heart disease, hypertension, stroke, some forms of cancer, and osteoarthritis.³ Although it is widely accepted that high-fat diets and physical inactivity are preventable risk factors,⁴ obesity continues to increase.^1,2,5There is a growing interest in the relationship between psychosocial risk factors and excess body fat accumulation.^6–16 In particular, some evidence suggests that psychosocial stressors may play a role in disease progression in general and in excess body fat in particular.^7,8,17 The key factors underlying physiological reactions to psychosocial stress have not been completely elucidated, but McEwen and Seeman¹⁷ and others^7,18,19 posit that the continued adaptation of the physiological system to external challenges alters the normal physiological stress reaction pathways and that these changes are related to adverse health outcomes.^8,17,18,20 For example, in examining the association between psychosocial stress and excess body fat accumulation, Björntorp and others have suggested that psychosocial stress is linked to obesity, especially in the abdominal area.^7,8Perceived discrimination, as a psychosocial stressor, is now receiving increased attention in the empirical health literature.^21–24 Such studies suggest perceived discrimination is inversely related to poor mental and physical health outcomes and risk factors, including hypertension,^24,25 depressive symptoms,^26–28 smoking,^29–31 alcohol drinking,^32,33 low birthweight,^34,35 and cardiovascular outcomes.^36–38Internalized racism, the acceptance of negative stereotypes by the stigmatized group,³⁹ has also been recognized as a race-related psychosocial risk factor.⁴⁰ Recent studies have also suggested that race-related beliefs and experiences including perceived discrimination might be potentially related to excess body fat accumulation. Three of these studies^9,13,41 showed that internalized racism was associated with an increased likelihood of overweight or abdominal obesity among Black Caribbean women in Dominica⁴¹ and Barbados¹³ and adolescent girls in Barbados.⁹ These researchers posit that individuals with relatively high levels of internalized racism have adopted a defeatist mindset, which is believed to be related to the physiological pathway associated with excess body fat accumulation. However, Vines et al.¹⁶ found that perceived racism was associated with lower waist-to-hip ratios among Black women in the United States. Although the assessment of race-related risk factors varied across these studies, the findings suggest that the salience of race-related beliefs and experiences may be related to excess body fat accumulation.Collectively, the results of these studies are limited. First, because they examined the relationship between race-related beliefs and experiences and excess body fat only among women, we do not know if this relationship is generalizable to men.^13,16,41 Second, these studies only examined this relationship among Blacks, even though perceived unfair treatment because of race/ethnicity has been shown to be adversely related to the health of multiple racial/ethnic population groups in the United States^42–49 and internationally.^27,50–55 Third, none of the studies have examined the relationship between excess body fat accumulation and perceived nonracial/nonethnic experiences of interpersonal discrimination. Some evidence suggests that the generic perception of unfair treatment or bias is adversely related to health, regardless of whether it is attributed to race, ethnicity, or some other reason.^45,55,56 Fourth, none of these studies included other measures of stress. We do not know if the association between race-related risk factors and obesity is independent of other traditional indicators of stress.Using a multiethnic, population-based sample of adults, we examined the association of perceived discrimination and obesity independent of other known risk factors for obesity, including stressful major life events. Additionally, because reports of perceived racial/ethnic discrimination and non-racial/ethnic discrimination vary by racial/ethnic groups^24,45,46,57 and because Whites tend to have less excess body fat than do Blacks and Hispanics,^1,3 we examined the relationships between perceived discrimination and excess body fat accumulation among Hispanics, non-Hispanic Whites, and non-Hispanic Blacks.     

Reinforcement of smoking and drinking: tobacco marketing strategies linked with alcohol in the United States

Objectives. We investigated tobacco companies’ knowledge about concurrent use of tobacco and alcohol, their marketing strategies linking cigarettes with alcohol, and the benefits tobacco companies sought from these marketing activities.Methods. We performed systematic searches on previously secret tobacco industry documents, and we summarized the themes and contexts of relevant search results.Results. Tobacco company research confirmed the association between tobacco use and alcohol use. Tobacco companies explored promotional strategies linking cigarettes and alcohol, such as jointly sponsoring special events with alcohol companies to lower the cost of sponsorships, increase consumer appeal, reinforce brand identity, and generate increased cigarette sales. They also pursued promotions that tied cigarette sales to alcohol purchases, and cigarette promotional events frequently featured alcohol discounts or encouraged alcohol use.Conclusions. Tobacco companies’ numerous marketing strategies linking cigarettes with alcohol may have reinforced the use of both substances. Because using tobacco and alcohol together makes it harder to quit smoking, policies prohibiting tobacco sales and promotion in establishments where alcohol is served and sold might mitigate this effect. Smoking cessation programs should address the effect that alcohol consumption has on tobacco use.Smoking remains the leading preventable cause of premature mortality in the United States, accounting for more than 440 000 deaths annually.¹ Alcohol consumption is the third-leading cause of mortality in the nation.² Each year, approximately 79 000 deaths are attributable to excessive alcohol use.³ The concurrent use of cigarettes and alcohol further increases risks for certain cancers, such as cancer of the mouth, throat, and esophagus.^4,5 In addition, the use of both tobacco and alcohol makes it more difficult to quit either substance.⁶Smoking and drinking are strongly associated behaviors.^7–13 Smokers are more likely to drink alcohol,¹¹ drink more frequently,^8,11 consume a higher quantity of alcohol,^8,11,14 and demonstrate binge drinking (5 or more drinks per episode) than are nonsmokers.^9,11,12 Alcohol drinkers, especially binge drinkers, are also more likely to smoke^7,8,10 and are more likely to smoke half a pack of cigarettes or more per day.¹⁰The association between tobacco use and alcohol use becomes stronger with the heavier use of either substance.^8,15,16 Alcohol consumption increases the desire to smoke,^17,18 and nicotine consumption increases alcohol consumption.¹⁹ Experimental studies have demonstrated that nicotine and alcohol enhance each other''s rewarding effects.^16,18 Alcohol increases the positive subjective effects of smoking,^8,15,16,20 and smoking while using alcohol is more reinforcing than is smoking without concurrent alcohol use.⁸ Smokers smoke more cigarettes while drinking alcohol,^8,15,18 especially during binge-drinking episodes.^8,15 This behavior has also been observed among nondaily smokers^8,15 and light smokers.¹⁷The concurrent use of alcohol and tobacco is common among young adults,^8,10,12,21 including nondaily smokers,^19,22–24 nondependent smokers,⁸ and novice smokers.¹³ Young adult smokers have reported that alcohol increases their enjoyment of and desire for cigarettes^8,25 and that tobacco enhances the effect of alcohol: it “brings on the buzz” or “gave you a double buzz.”^13,23,26 Young adult nondaily smokers described the pairing of alcohol and cigarettes as resembling “milk and cookies” or “peanut butter with jelly.”²⁴ Young adults have also been the focus of aggressive tobacco promotional efforts in places where alcohol is consumed, such as bars and nightclubs.^27,28Consumer products often fall into cohesive groups (sometimes referred to as “Diderot unities”) that may reinforce certain patterns of consumption,²⁹ and these groupings may be influenced by marketing activities. In the case of tobacco and alcohol, these product links may have been further enhanced by cooperation between tobacco and alcohol companies (e.g., cosponsorship) or corporate ownership of both tobacco and alcohol companies (e.g., Philip Morris''s past ownership of Miller Brewing Company).We used tobacco industry documents to explore tobacco companies’ knowledge regarding linked tobacco and alcohol use and the companies’ marketing strategies that linked cigarettes with alcohol. We were interested in 3 basic issues: (1) what tobacco companies knew about the association between drinking and smoking, especially about smokers’ drinking behaviors, (2) how tobacco and alcohol companies developed cross promotions featuring cigarettes and alcohol, and (3) how tobacco companies linked cigarettes with alcohol in their marketing activities and the benefits they expected to gain from those activities.     

Effectiveness of a Risk Screener in Identifying Hepatitis C Virus in a Primary Care Setting

Objectives. We evaluated an intervention designed to identify patients at risk for hepatitis C virus (HCV) through a risk screener used by primary care providers.Methods. A clinical reminder sticker prompted physicians at 3 urban clinics to screen patients for 12 risk factors and order HCV testing if any risks were present. Risk factor data were collected from the sticker; demographic and testing data were extracted from electronic medical records. We used the t test, χ² test, and rank-sum test to compare patients who had and had not been screened and developed an analytic model to identify the incremental value of each element of the screener.Results. Among screened patients, 27.8% (n = 902) were identified as having at least 1 risk factor. Of screened patients with risk factors, 55.4% (n = 500) were tested for HCV. Our analysis showed that 7 elements (injection drug use, intranasal drug use, elevated alanine aminotransferase, transfusions before 1992, ≥ 20 lifetime sex partners, maternal HCV, existing liver disease) accounted for all HCV infections identified.Conclusions. A brief risk screener with a paper-based clinical reminder was effective in increasing HCV testing in a primary care setting.Hepatitis C virus (HCV) is a significant public health problem. With 3.2 million Americans chronically infected,1 HCV is the leading cause of liver-related deaths,2 accounting for 15 000 deaths in 2007.3 Although earlier treatments were moderately effective in reducing the HCV disease burden,4 new treatments with greater promise have become available.5 Because treatment cannot be offered without diagnosis and 45% to 85% of patients with HCV are unaware of their infection,6,7 interventions designed to increase the number of HCV cases diagnosed are urgently needed.Guidelines for HCV screening vary. The Centers for Disease Control and Prevention (CDC) recommends that patients who have injected drugs, who have long-term hemodialysis histories or persistently abnormal alanine aminotransferase (ALT) levels, who had blood transfusions or organ transplants before July 1992 (when HCV was eradicated from the nation’s blood supply), who have been exposed to HCV (e.g., their mothers were HCV positive or they have been exposed at their workplace), or who are HIV positive8 be assessed for HCV risk. Other authorities have expanded recommendations to include current sexual partners of individuals with HCV,9,10 people who have had multiple sex partners, intranasal cocaine users, people with tattoos or repeated body piercings, people with high levels of daily alcohol use over time, Vietnam-era veterans,11 and immigrants from countries with high HCV prevalence rates.12In addition, with respect to research on HCV risk, various studies have shown that homelessness, incarceration,13 tattoos,14 barbershop shaving,15 body piercing,16 ear piercing among men,17 use of intranasal drugs and crack cocaine,18 and mental illness19 are associated with higher risk. Although not explicitly recommending testing, this literature suggests that these are potential HCV risk factors for which screening may be appropriate.Multiple approaches can be used in HCV testing programs. Universal screening of people with identified risks appears to best meet CDC’s recommendations and to be the most efficient strategy, given that individuals with identified risk factors have been shown to have a much higher prevalence of HCV than the general population.1 As the front-line health care providers for most Americans, primary care settings offer an important opportunity to incorporate HCV risk assessments, although examination of this model has been limited.In 2 studies conducted in primary care settings, patient self-administered questionnaires have been used to assess HCV risk screening. In one of these studies, set in an urban clinic, patients completed a 27-item risk assessment20; the other study, set in a Veterans Health Administration facility, involved a retrospective analysis of HCV testing among veterans who had reported HCV risk factors on a self-administered questionnaire.21 To date, no HCV screening tools have been validated, and no studies comparing different types of interventions have been conducted, including comparisons of patient-completed screening instruments and screeners implemented by primary care providers (PCPs).We implemented a PCP-based risk screening intervention that successfully increased rates of HCV testing among patients at risk.22 Because existing guidelines do not concur on what factors should trigger HCV testing, we included a moderately large number of risk factors (12) in assessing the intervention. However, it was unknown which factors of the screening intervention were responsible for the screener’s success and whether an abbreviated set of risk factors would be equally successful. To inform both the development of a parsimonious screening intervention and the revision of risk-based HCV testing guidelines, we examined which factors were the strongest independent predictors of testing and diagnosis of HCV.The Hepatitis C Assessment and Testing project (HepCAT), a prospective cross-sectional evaluation conducted in 3 urban primary care clinics, was designed to inform CDC’s revision of its HCV testing recommendations. HepCAT’s major goal was to evaluate an intervention designed to identify patients at risk for HCV with a PCP-implemented risk screener and test those identified as at risk. Another objective was to parse out a limited number of factors to include in a simple and effective screener. We hypothesized that using the risk screener would increase testing rates and that a brief screener incorporating fewer risk factors would perform as well as the full screener. We examined the performance of the screener overall as well as the extent to which each specific risk factor predicted HCV.     

Health Among Caregivers of Children With Health Problems: Findings From a Canadian Population-Based Study

Objectives. We used population-based data to evaluate whether caring for a child with health problems had implications for caregiver health after we controlled for relevant covariates.Methods. We used data on 9401 children and their caregivers from a population-based Canadian study. We performed analyses to compare 3633 healthy children with 2485 children with health problems. Caregiver health outcomes included chronic conditions, activity limitations, self-reported general health, depressive symptoms, social support, family functioning, and marital satisfaction. Covariates included family (single-parent status, number of children, income adequacy), caregiver (gender, age, education, smoking status, biological relationship to child), and child (age, gender) characteristics.Results. Logistic regression showed that caregivers of children with health problems had more than twice the odds of reporting chronic conditions, activity limitations, and elevated depressive symptoms, and had greater odds of reporting poorer general health than did caregivers of healthy children.Conclusions. Caregivers of children with health problems had substantially greater odds of health problems than did caregivers of healthy children. The findings are consistent with the movement toward family-centered services recognizing the link between caregivers'' health and health of the children for whom they care.Caring for a child with health problems can entail greater than average time demands,^1,2 medical costs,^3,4 employment constraints,^5,6 and childcare challenges.^6–8 These demands may affect the health of caregivers, a notion supported by a variety of small-scale observational studies that have shown increased levels of stress, distress, emotional problems, and depression among caregivers of children with health problems.^1,2,5,9–12Whether these problems are caused by the additional demands of caring for children with health problems or by confounding variables is difficult to answer definitively. The literature reports the identification of a variety of factors purported to be associated with caregiver health, including contextual factors such as socioeconomic status^13–17; child factors such as level of disability,^{1,11,13,18–21} presence of behavior problems,^22–25 and overall child adjustment²⁶; and caregiver-related characteristics such as coping strategies^11,22,27 and support from friends and family.^15,17,28,29 In general, this work has been based on small clinic-based samples^9,30 or specific child populations (e.g., cerebral palsy,^5,25 attention-deficit/hyperactivity disorder^31,32), and typically has been hampered by limited generalizability and a lack of careful, multivariate analysis. Furthermore, most studies have focused on caregivers'' psychological health,^1,2,5,9–12 although physical health effects may also exist among caregivers.^5,19,25,33One of the few studies to involve large-scale, population-based data compared the health of 468 caregivers of children with cerebral palsy to the health of a population-based sample of Canadian parents.⁵ The study showed that caregivers of children with cerebral palsy had poorer health on a variety of physical and psychological health measures. Furthermore, the data were consistent with a stress process model,^5,25 which proposes that additional stresses associated with caring for a child with cerebral palsy directly contribute to poorer caregiver health. However, these findings were based on a specific subpopulation of caregivers and univariate comparisons that could not control for potentially important confounders such as variation in caregiver education, income, and other demographic factors.We used population-based data to test the hypothesis that the health of caregivers of children with health problems would be significantly poorer than that of caregivers of healthy children, even after we controlled for relevant covariates. Our approach of using large-scale, population-based data representing a broad spectrum of childhood health problems³⁴ makes 4 key contributions to the current literature. First, our use of population-based data rather than small-scale, clinic-based studies yielded results that are potentially generalizable to a wide group of caregivers caring for children with health problems. Second, our examination of children with and without health problems allowed us to examine caregiver health effects across a wide variety of caregiving situations. Third, consideration of physical health outcomes (in addition to more regularly studied psychological outcomes) increased our knowledge of the breadth of caregiver health issues. Finally, controlling for relevant covariates allowed us to rule out a number of alternative explanations for caregiver health effects.     

Intergenerational relationships between the smoking patterns of a population-representative sample of US mothers and the smoking trajectories of their children

Objectives. We assessed intergenerational transmission of smoking in mother-child dyads.Methods. We identified classes of youth smoking trajectories using mixture latent trajectory analyses with data from the Children and Young Adults of the National Longitudinal Survey of Youth (n = 6349). We regressed class membership on prenatal and postnatal exposure to maternal smoking, including social and behavioral variables, to control for selection.Results. Youth smoking trajectories entailed early-onset persistent smoking, early-onset experimental discontinued smoking, late-onset persistent smoking, and nonsmoking. The likelihood of early onset versus late onset and early onset versus nonsmoking were significantly higher among youths exposed prenatally and postnatally versus either postnatally alone or unexposed. Controlling for selection, the increased likelihood of early onset versus nonsmoking remained significant for each exposure group versus unexposed, as did early onset versus late onset and late onset versus nonsmoking for youths exposed prenatally and postnatally versus unexposed. Experimental smoking was notable among youths whose mothers smoked but quit before the child''s birth.Conclusions. Both physiological and social role-modeling mechanisms of intergenerational transmission are evident. Prioritization of tobacco control for pregnant women, mothers, and youths remains a critical, interrelated objective.Women who smoke during pregnancy are more likely to have offspring who become adolescent smokers.^1–7 Studies link mother''s smoking during pregnancy with youths'' earlier smoking initiation,^3,7–9 greater persistence in regular smoking,^3,7 and stronger nicotine dependency.^6,8,10,11Hypothesized physiological pathways for mother-to-child transmission of smoking are reviewed elsewhere^12–14 and may include inherited susceptibility to addiction alone or in combination with in utero neurodevelopmental exposure and scarring that activates nicotine susceptibility. Furthermore, because few women who smoke during pregnancy quit after delivery^15,16 higher rates of smoking among offspring may reflect role modeling of maternal smoking behavior. Notably, parental smoking is hypothesized to demonstrate pro-smoking norms and solidify pro-smoking attitudes.^17,18Studies considering both smoking during pregnancy and subsequent maternal smoking outcomes have sought to distinguish between these proposed social and physiological transmission pathways.^{1–4,6,7,9,19} Similarly, studies controlling for family sociodemographic factors^{1,2,4,5,7,8,10,11,19,20} or maternal propensity for health or risk taking^1,2,9,10 have sought to further distinguish direct physiological or social transmission from selection. Studies considering children''s cognitive and behavioral outcomes have shown that selection by maternal social and behavioral precursors to smoking during pregnancy strongly biases findings on smoking during pregnancy^21,22; however, it remains unclear whether this is also the case for youth smoking. Some studies^2,3,5,6,19 have observed that smoking during pregnancy operates independently of subsequent maternal smoking. A few have found that smoking during pregnancy is only independently associated in select analyses (e.g., for initiation but not frequency or number of cigarettes^6,9 or only among females^7,20). Several have found that smoking during pregnancy does not operate independently of subsequent maternal smoking behavior,^1,4 and the remaining studies do not address postnatal maternal smoking.^8,9,11We explored whether these inconsistencies in findings supporting social or physiological mechanisms for intergenerational transmission can be accounted for by more comprehensively examining maternal and child smoking behavior. Previous work has established the advantages of statistical models for youth smoking trajectories that capture initiation, experimentation, cessation, or continued use.^23–28 Studies focusing on parental smoking concurrent with youth smoking suggest that postnatal exposures may differentially predispose youths for specific smoking trajectories.^24,26–28 Only 3 known studies have considered whether smoking during pregnancy influences youth smoking progression, and these have shown greater likelihood of early regular use^3,11 and telescoping to dependence.⁸ However, limitations of sample selectivity and measurement and modeling of maternal and youth smoking outcomes restrict the generalizability and scope of these findings.²⁹ To specifically address these limitations and more comprehensively assess hypothesized intergenerational transmission pathways, we used US population–representative data, latent variable techniques, and a rich set of data on maternal and youth smoking and social and behavioral selection factors. We characterized trajectories of youth smoking from adolescence through young adulthood and considered exposure to various maternal smoking patterns from prebirth to the child''s early adolescence.     

Correlates of incarceration among young methamphetamine users in Chiang Mai, Thailand

Objectives. We examined correlates of incarceration among young methamphetamine users in Chiang Mai, Thailand in 2005 to 2006.Methods. We conducted a cross-sectional study among 1189 young methamphetamine users. Participants were surveyed about their recent drug use, sexual behaviors, and incarceration. Biological samples were obtained to test for sexually transmitted and viral infections.Results. Twenty-two percent of participants reported ever having been incarcerated. In multivariate analysis, risk behaviors including frequent public drunkenness, starting to use illicit drugs at an early age, involvement in the drug economy, tattooing, injecting drugs, and unprotected sex were correlated with a history of incarceration. HIV, HCV, and herpes simplex virus type 2 (HSV-2) infection were also correlated with incarceration.Conclusions. Incarcerated methamphetamine users are engaging in behaviors and being exposed to environments that put them at increased risk of infection and harmful practices. Alternatives to incarceration need to be explored for youths.Over the past decade, methamphetamine use has increased exponentially and reached epidemic proportions, particularly in North America¹ and Southeast Asia.² The methamphetamine epidemic has been concentrated among adolescents and young adults and has significant public health implications² because methamphetamine use has been associated with high-risk behaviors including multiple sexual partners, contractual sex, polydrug use, and aggression.^3,4Thailand has experienced a steadily increasing methamphetamine epidemic since 1996.⁵ By 2003, an estimated 3 500 000 Thais had ever used methamphetamines.⁶ In 1996, Thailand criminalized methamphetamines, treating the trafficking, possession, and use of methamphetamines with the same severity as heroin-related offenses.⁷ In 2003 the government began a “war on drugs” in an attempt to control the epidemic.^8,9 In combination, these events led to a doubling in the number of incarcerated individuals between 1996 and 2004.^7,10 In 2005, 64% of Thai inmates were drug offenders,¹¹ and in 2006, 75% of drug-related arrests and charges were related to methamphetamines.¹² Treatment for methamphetamine use is limited. Institutional management of methamphetamine users includes the use of rehabilitation centers, military-style boot camps, compulsory drug treatment centers, and prisons.¹¹A history of incarceration has been associated with negative health outcomes, including sexually transmitted infections (STIs) and blood-borne viruses, particularly syphilis,¹³ herpes,¹⁴ HIV,^10,15,16 hepatitis b (HBV),^17,18 and HCV.^18–21 The prevalence of these pathogens has been found to be much higher in prisons than in the general population.^22–26 Although these infections may be a result of a high-risk lifestyle leading to incarceration, it is also clear that the prison system exposes individuals to environments and behaviors that increase their risk of acquiring these infections, such as tattooing,^{10,18,21,27–29} unprotected sex as a result of limited condom availability,²⁷ and using shared needles to inject drugs.^27,30,31With so many young methamphetamine users entering the judicial system, it is important to understand the characteristics of this group so that appropriate public health interventions can be designed. Young methamphetamine users need to be diverted away from the judicial system to decrease high-risk behaviors that may impact their own well-being and that of the community.As part of a randomized controlled trial to reduce the risks associated with methamphetamine use among youths in Chiang Mai, Thailand, we investigated behavioral and viral correlates of incarceration among a sample of 1189 young adults aged 18 to 25 years.     

Life-Course Socioeconomic Position and Incidence of Diabetes Mellitus Among Blacks and Whites: The Alameda County Study, 1965�C1999

Objectives. We examined associations between several life-course socioeconomic position (SEP) measures (childhood SEP, education, income, occupation) and diabetes incidence from 1965 to 1999 in a sample of 5422 diabetes-free Black and White participants in the Alameda County Study.Methods. Race-specific Cox proportional hazard models estimated diabetes risk associated with each SEP measure. Demographic confounders (age, gender, marital status) and potential pathway components (physical inactivity, body composition, smoking, alcohol consumption, hypertension, depression, access to health care) were included as covariates.Results. Diabetes incidence was twice as high for Blacks as for Whites. Diabetes risk factors independently increased risk, but effect sizes were greater among Whites. Low childhood SEP elevated risk for both racial groups. Protective effects were suggested for low education and blue-collar occupation among Blacks, but these factors increased risk for Whites. Income was protective for Whites but not Blacks. Covariate adjustment had negligible effects on associations between each SEP measure and diabetes incidence for both racial groups.Conclusions. These findings suggest an important role for life-course SEP measures in determining risk of diabetes, regardless of race and after adjustment for factors that may confound or mediate these associations.Diabetes mellitus is a major cause of morbidity and mortality in the United States.^1,2 Type 2 diabetes disproportionately affects Hispanics, as well as non-Hispanic Black Americans, American Indians/Alaska Natives, and some Asian/Pacific Islander groups. In the United States, members of racial and ethnic minority groups are almost twice as likely to develop or have type 2 diabetes than are non-Hispanic Whites.^2–5 Significant racial and ethnic differences also exist in the rates of diabetes-related preventive services, quality of care, and disease outcomes.^6–10Researchers have attempted to determine why, relative to Whites, members of racial and ethnic minority groups are disproportionately affected by diabetes. For example, compared with White Americans, Black Americans are presumed to have stronger genetic^5,11 or physiological^11–13 susceptibility to diabetes, or greater frequency or intensity of known diabetes risk factors, such as obesity, physical inactivity, and hypertension.^14–17Black Americans also are more likely than are White Americans to occupy lower socioeconomic positions.¹⁸ Low socioeconomic position (SEP) across the life course is known to influence the prevalence^19–24 and incidence^3,19,25–30 of type 2 diabetes. The risk of diabetes also is greater for people who are obese,^3,17,31 physically inactive,^3,32 or have hypertension,^33,34 all of which are conditions more common among people with lower SEP.^16,35–37Several studies have focused on the extent to which socioeconomic factors, body composition (i.e., weight, height, body mass index, and waist circumference), and behaviors explain the excess risk of diabetes attributed to race.^4,12,19,30 For example, 2 separate studies, one with data from the Health and Retirement Study¹⁹ and the other with data from the Atherosclerosis Risk in Communities Study,³⁰ used race to predict diabetes incidence. Attempting to separate the direct and indirect effects of race on diabetes,³⁸ these studies assessed, via statistical adjustment, which socioeconomic measures and diabetes-related risk factors, when adjusted, could account for the excess risk among Black participants relative to White participants.^19,30 Adjustment for education lessened the effect of Black race on diabetes incidence in the Atherosclerosis Risk in Communities Study.³⁰ In the Health and Retirement Study, excess risk attributed to Black race was not explained by early-life socioeconomic disadvantage, but it was reduced after adjustment for education and later-life economic resources.¹⁹ The validity of this analytic approach has been challenged, however, because the socioeconomic measures used were assumed to have the same meaning across all racial/ethnic groups, a questionable assumption³⁸ in the United States, especially in 1965.We sought to explore the predictive effects of several life-course socioeconomic factors on the incidence of diabetes among both Black and White Americans. We examined demographic confounders (age, gender, marital status) and diabetes risk factors (obesity, large waist circumference, physical inactivity, high blood pressure, depression, access to health care) as possible mediators of the observed associations between SEP and incident diabetes (i.e., the development of new cases of diabetes over time).     

Awareness of HCV Infection Among Persons Who Inject Drugs in San Diego,California

We asked persons who inject drugs questions about HCV, including past testing and diagnosis followed by HCV testing.Of 540 participants, 145 (27%) were anti-HCV positive, but of those who were positive, only 46 (32%) knew about their infection. Asking about previous HCV testing results yielded better results than did asking about prior HCV diagnosis. Factors associated with knowing about HCV infection included older age, HIV testing, and drug treatment.Comprehensive approaches to educating and screening this population for HCV need implementation.HCV causes chronic infection in about 75% to 85% of infected persons, potentially leading to cirrhosis and liver cancer.1 Currently in the United States, chronic HCV infection affects an estimated 2.7 million persons.2 Injection drug use is the leading risk factor for infection.3,4Because self-report of HCV infection might be used to make decisions on who to screen, the limitations of self-report need to be better understood. Past studies on the limitations of self-reported HCV infection have generally described poor agreement between actual and perceived HCV serostatus.5,6 In persons with HCV infection, behavioral counseling can be provided to reduce disease progression (alcohol abstinence) and to reduce HCV transmission (sharing injection equipment).7 We investigated the sensitivity and specificity of perceived compared with actual HCV serostatus and assessed whether awareness of HCV infection is associated with differences in risk behaviors among HCV-positive persons who inject drugs (PWID).